Claim for Continuance of Compensation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CA-12 Claim for Continuance of Compensation Under the Federal Employees' Compensation Act	Form	Modified	Available
average production workers 2006 2007.doc	Supplementary Document	Uploaded 2008-02-21	Available
5 USC 8133 FECA.doc	Supplementary Document	Uploaded 2008-02-21	Available
20 CFR 10.414.doc	Supplementary Document	Uploaded 2008-02-21	Available
DOL_GOVT-1.doc	Supplementary Document	Uploaded 2008-02-21	Available
Supporting Statement for 1215-0154 (CA-12) November 2007.doc	Supporting Statement A	Uploaded 2008-02-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
13838	Claim for Continuance of Compensation	Form	Modified	Claim for Continuance of Compensation Under the Federal Employees' Compensation Act

ICR Details

OMB Control No: 1215-0154	ICR Reference No: 200802-1215-003
Status: Historical Active	Previous ICR Reference No: 200503-1215-002
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Claim for Continuance of Compensation
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/28/2008
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/25/2008
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2011	36 Months From Approved	06/30/2008
Responses	4,850	0	5,450
Time Burden (Hours)	403	0	454
Cost Burden (Dollars)	1,988	0	2,000

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Abstract: This form is used to obtain information from eligible survivors receiving death benefits for an extended period of time. This information is necessary to ensure that compensation being paid is accurate.

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Authorizing Statute(s): US Code: 5 USC 8133 Name of Law: Federal Employees' Compensation Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 69230	12/07/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 22432	04/25/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Claim for Continuance of Compensation	CA-12	Claim for Continuance of Compensation Under the Federal Employees' Compensation Act

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	4,850	5,450	0	0	-600	0
Annual Time Burden (Hours)	403	454	0	0	-51	0
Annual Cost Burden (Dollars)	1,988	2,000	0	0	-12	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The number of persons receiving death benefits has decreased by 600 from 5450 to 4850, leading to a decrease in the burden hours from 454 to 403 - a decrease of 51 - and a decrease in cost burden of $12.

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Annual Cost to Federal Government: $13,704

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/25/2008

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